Some cutters use a razor blade for the female genital mutilation procedure.

Ivan Lieman/Barcroft Media via Getty Images

Editor's note: Given the subject this story explores, the discussion includes some explicit language.

Two sisters from a remote pastoral village in Puntland State, Somalia, died on Sept. 11 of complications from a female genital mutilation (FGM) procedure.

An "inexperienced self-proclaimed traditional circumciser" performed the procedure the day before, according to Dr. Mohamed Hussein Aden, director of the University Teaching Hospital in Galkayo, Somalia, who sent an email with his comments to NPR.

According to Aden, the procedure caused profuse bleeding, and the girls died of hemorrhagic shock en route to the hospital, about 75 miles from the location of the procedure.

Aden indicated that the girls — Aasiyo Farah Abdi Warsame, 10, and Khadijo, 11 — underwent the form of FGM known as infibulation, in which the clitoris and labia are cut and re-stitched to narrow the vaginal opening.

Claudia Cappa, senior adviser of statistics for child protection and development at UNICEF, told NPR that infibulation is commonly practiced in Somalia and is the most invasive type of FGM procedure.

"Infibulation is the most severe form of FGM and cutting, which [can] result in the death of the girl," Cappa says.

The deaths of the two sisters this week follow the death of another Somali girl, Deeqa Nuur, 10, in July 2018, who also hemorrhaged after an FGM procedure.

The cases underscore concerns about FGM in Somalia, which the U.N. says has the highest prevalence in the world. Ninety-eight percent of women between the ages of 15 and 49 have undergone FGM. The practice is legal in Somalia.

Worldwide, UNICEF estimates that more than 200 million women and girls have experienced some form of FGM.

This coming-of-age ritual can take several forms, from partial or total removal of the clitoris to the removal of folds of flesh around the vagina to narrowing the vaginal opening. The U.N. designates it as a human rights violation. But in societies where FGM is practiced, women who have not undergone the procedure may have a difficult time finding a marriage partner.

The earlier death in Somalia had prompted a strong response from the government.

Somalia's attorney general Ahmed Ali Dahir announced that efforts would be made to prosecute the individual who performed the FGM procedure. Reuters has reported that Nuur's family hindered the investigation by withholding information.

"Deeqa's family seems to have held things back as they continue to believe that FGM is not wrong," says Brendan Wynne, spokesman for Donor Direct Action, a U.S. organization that works with grassroots organizations that seek to eliminate FGM.

Nimco Ali is a British Somali activist who underwent FGM herself and has founded Daughters of Eve, a nonprofit group that opposes the practice. She wonders about the progress made by the Somali government since the announcement of the prosecution in July.

"I believe that the AG was doing this all for press. When the cameras are not there, I doubt there is much interest in the Deeqa case or any others," Ali says.

"As [a] medical community, we are dismayed, disarrayed and shocked [by the] brutal action and the cold-blooded loss of our beloved daughters," Aden writes in his email. "The cruel practice is deeply rooted and protected in our society. Believe me, we have to wage a war to eliminate it."